The NHS bureaucracy

that doesn't know how

many people it employs

John Womersley

 

For over a decade there has been an abundance of evidence from political and health service commentators, from health professionals and from investigations by public bodies of inefficiency and waste in the NHS. In Scotland there can be no more compelling examples than the following:
     Health and Sport Committee of the Scottish Parliament, May 2010: NHS Board Revenue Allocation
     'There is a sense that things (in NHS boards) have been allowed to drift during the years of financial growth with inefficiencies allowed to continue.'
     'The mechanisms for holding NHS boards to account – annual reviews and performance against targets – do not adequately address efficiency.'
     'Staff have seemingly been employed in jobs that have no productive value.'     
     Audit Scotland, June 2011: Community Health Partnerships
     'The bodies charged with bringing council and health service staff together to plan community care have largely failed to deliver improvements, and some do not even know how many staff they manage. In areas where they might have been expected to make a difference, such as reducing the number of patients blocking hospital beds and reducing emergency admissions the problem is getting worse. There should be a fundamental review of the entire CHP system, which is responsible for spending £3.2 billion a year.'
     The following comments were reported in the Herald (June 2011):
     The British Medical Association in Scotland: 'The partnerships are bureaucratic monoliths caught up in their own internal processes rather than helping to organise services to meet patients' needs. It is deeply disturbing that, with responsibility for such a significant sum of NHS funding and despite the many bureaucrats working for these organisations, their financial management, strategy and governance is so poor. That a CHP cannot say how many staff it has, or how much it has spent on administration costs, is beyond belief.'
     Scottish Labour's health spokeswoman Jackie Baillie: 'The fact that a CHP cannot say how many staff it has working for it is simply staggering. I urge the Scottish Government to undertake a wide-ranging review of the structure and function of CHPs to ensure they are fit for purpose. Doing nothing is simply not an option.'
     Scottish Conservative spokesman Murdo Fraser: 'This report confirms extremely poor management and governance of CHPs.'
     Jenny Stewart of auditors KPMG: 'This very clear report highlights a rather depressing picture – much duplication, areas of inefficiency and, more fundamentally, health outcomes worsening in many CHP areas.'

 

     During the last decade the NHS – health boards (including their constituent CHPs) and central government – has been allowed to mushroom in an uncoordinated and unregulated manner, sprouting in all directions. Managers have been allowed to establish bureaucracies that are self-serving and lacking in accountability. Accountability is well nigh zero, Board members speak with one voice: individual members very rarely express their opinion publicly and never reply to letters or emails addressed to them personally.
     Since 1978 community health services in the Glasgow Health Board area have been managed successively as five health districts, three sectors, a community/mental health trust, a primary care trust, as local health cooperatives, part of a rehabilitation and assessment directorate (RAD) and then as community health and care partnerships (CHCPs) and community health partnerships (CHPs).
     Planning and reorganisation has been perpetual, the focus being on change in structures and processes with an eye to creating job opportunities for managers rather than on improving services. This constant and complex restructuring is carried out on the basis of no evidence, with no trials conducted. It creates uncertainty and demoralisation for staff and is extremely disruptive to services The change to CH(C)Ps created nine new bureaucracies with their own management structure, premises, websites, self-promotional activities, 'consultations' with users, and public participatory events. It also made it difficult to make the most effective and equitable use of specialist expertise and services.
     Last year NHS Greater Glasgow and Clyde announced yet another major reorganisation – to replace its five CHCPs in Glasgow City with a single CHP comprising three sectors and a HQ function. The discussion paper made no reference to patients, frontline staff or the public. It gave no explanation of the problems that it aimed to address or of the need for change; and there was no mention of experience to date with the existing CHPs and CHCPs. Nor was there mention of the need to cut management costs or to reduce waste.
     Possible savings of up to £450,000 pa in management costs were mentioned, but, surely outrageously, only if 'we are able to actually reduce the number of staff through redeployment or turnover'. New posts included section heads of planning; professional advisors; 'oversight of the relationships with CHP stakeholders'; 'interface with corporate and other city council directors'; a business support post; centre heads of human resources, finance, performance, organisational development and health improvement; sector directors, each with a considerable number of support posts that are themselves supported by a planning manager – and so on.
     In the 1980s the entire Greater Glasgow Health Board (community and acute services) was managed in three districts with a HQ function. Some might remember Gary Macfarlane, the Kirkintilloch general practitioner/politician, suggesting that it should be possible to run the board from a car – an administrator, finance officer, medical officer and a chief executive, with a PC in the boot. Management costs (including public health doctors) were limited to 6% of the health board budget.
     In those days it was possible for any member of staff or the public to approach the appropriate one of the four officers about any aspect of their health service and to get a considered reply and often some action. Nowadays it is almost impossible to identify who is in charge, and when lucky enough to do so even helpful criticism is channelled into a formal complaints procedure and responded to defensively or with denial. At the same time membership of the board itself has increased by almost three-fold to 32 – ostensibly to improve representation and accountability. But how can this be when members are unwilling to challenge the executive and appear afraid to speak out or rock the boat in any way?
     It is more than high time for change, and for this we need a leader, not a legion of managers. And of course, to ensure accountability, the policeman.

John Womersley was a consultant in public health, NHS Greater Glasgow and Clyde, 1978-2006